Antenatal Hydronephrosis

Congenital Hydronephrosis
By: Dr. Sonali Paradhi Mhatre

Basics
 Kidneys are the major organs responsible for waste
product removal and maintaining fluid, pH &
electrolytes in the body.
 HYDRONEPHROSIS: Refers to a pathological
condition characterized by the distension of the
renal pelvis and calyces, as a result of stagnation or
reflux of urine.
 Ultrasound screening during pregnancy has resulted
in increasing recognition of fetal hydronephrosis.
 Fetal uropathies are detected by antenatal USG in 1%
of adequately monitored pregnancies.
Among these 50% are hydronephroses.

Embryologic Concepts
 Nephrogenesis, describes the embryologic
origins of the kidney, a major organ in the
urinary system.
 Starting from 4th wk & end on 36 wk of intra
uterine life.
 The development of the kidney proceeds
through a series of successive phases, each
marked by the development of a more advanced
kidney:
1. Pronephros
2. Mesonephros
3. Metanephros
 Active period of nephrogenesis between 20-
36wks, cease around 36 wks.

Physiologic fetal
hydronephrosis
 Compared with a newborn, a fetus has:
1. A relatively low renal vascular resistance
2. A relatively high renal blood flow
3. Higher glomerular filtration rate
4. A lower renal concentrating capacity
5. Therefore, a relatively high urine volume
 In addition, as the compliance of the ureter increases, it becomes
easier to expand.
 Since the fetal and neonatal kidneys are not fully developed, the
renal medullary cone may be transparent under ultrasound
examination, which leads to a wrong diagnosis of hydronephrosis.

Differential diagnosis of antenatally detected Hydronephrosis
ETIOLOGY % of all cases
Transient HN 41 – 80
Pelviureteric junction obstruction 10 – 30
Vesicoureteric reflux 10 – 20
Vesicoureteric junction obstruction,
Megaureters
5 – 10
Multicystic dysplastic kidney 4 – 6
Duplex kidney ( ± Ureterocele) 2 – 7
Posterior urethral valves 1 – 2
Others: Urethral atresia, Urogenital sinus,
Prune belly syndrome
Uncommon
Nguyen HT, Herndon
CA, Cooper C, Gatti J,
Kirsch A, Kokorowski P,
Lee R, Perez-Brayfield
M, Metcalfe P, Yerkes E,
Cendron M. The Society
for Fetal Urology
consensus statement
on the evaluation and
management of
antenatal
hydronephrosis. Journal
of pediatric urology.
2010 Jun 1;6(3):212-31.

Pathophysiology of Upper
Urinary Tract dilatation
 Obstruction
 Vesicoureteral Reflux
 Diuretic Phenomenon
 Spontaneous or Operative resolution of a
developmental anamoly

Important Embryological Timings
 GUT system formation starts from 4th wks GA.
 Urine formation starts from 10 wks GA.
 Ultrasound Milestones:
I. Bladder visible  10 wks GA
II. Kidneys detected  12- 13 wks GA
III. Filling / Empytying cycles  15 wks GA
IV. Perinephric Fat  20 wks GA
V. Ureters, Renal pelvis, calyces  Not visualized.

Antenatal
Monitoring
??Fetal
Interventions
Postnatal
Monitoring
??Micturating
Cystourethrogram
??Diuretic
Renography
??Antibiotic
Prophylaxis
??Surgical
Interventions

Antenatal Diagnosis
 Severity grading of Antenatal hydronephrosis is based on
anteroposterior diameter (APD) of renal pelvis.
 ANH is present if fetal renal APD ≥4mm in 2nd trimester and
≥7mm in 3rd trimester.
 Hydronephrosis is further graded as mild, moderate & severe.
 While lower cut-offs for defining HN increase the sensitivity for
detecting anamolies, it reduced specificity.
 Metaanalysis (2006) found that risk of postnatal pathology
increased with the degree of antenatal pelvic dilatation from
11.9% for mild, 45.1% for moderate and 88.3% for severe HN.
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Lee RS, Cendron M, Kinnamon DD, Nguyen HT. Antenatal hydronephrosis as a predictor of postnatal outcome: a meta-analysis. Pediatrics. 2006 Aug 1;118(2):586-93.

Antenatal Diagnosis
While fetuses with minimal pelvic dilatation have a low risk of
postnatal pathology, APD>15mm in any trimester represents
severe HN and prompts close monitoring.
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Nguyen HT, Herndon CA, Cooper C, Gatti J, Kirsch A, Kokorowski P, Lee R, Perez-Brayfield M, Metcalfe P, Yerkes E, Cendron M. The Society for Fetal Urology consensus statement on the evaluation and management of antenatal hydronephrosis.
Journal of pediatric urology. 2010 Jun 1;6(3):212-31.

Antenatal Monitoring
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Atleast 1 follow up
scan in 3rd trimester
Postnatal
evaluation
UNILATERAL
HN •Frequent Monitoring
needed.
•4-6 weekly scans
recommended
depending on severity,
oligohydroamnios.
Postnatal
Evaluation
BILATERAL
HN

 If antenatal HN is detected, it is recommended that an ultrasound at
16-20 wks GA also include evaluation of lower urinary tract obstruction,
renal dysplasia & extrarenal malformations.
 Signs suggestive of lower urinary tract obstruction:
1. Bilateral HN
2. Oligohydroamnios
3. Thick walled or dilated bladder
 Other poor prognostic signs include: Dilated posterior urethra,
perinephric urinoma, progressive calyceal or ureteric dilatation,
features suggesting renal dysplasia.
 Multiple studies have shown that the likelihood of aneuploidy in fetuses
with Antenatal HN is low, and hence doesn’t warrant Karyotyping in
each case.
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 Almost 80% of fetuses diagnosed with HN in 2nd trimester show
resolution or improvement.
 Persistent or worsening HN in 3rd trimester show higher rates of
postnatal pathology and warrant close watch.
 Multiple radiology studies have shown that 88% cases of mild
HN resolved in utero or neonatal period, while 1 in 3 neonates
with moderate or severe HN persisting in 3rd trimester required
postnatal surgery.
 Fetuses with signs of lower urinary tract obstruction, esp
oligohydroamnios need frequent monitoring and SOS may need
fetal or neonatal interventions.
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Prenatal Monitoring Algorhithm
Antenatal Hydronephrosis
Unilateral/ Mild
Hydronephrosis
Systemic
malformations along
with
Hydronephrosis
Bilateral / Severe
Hydronephrosis
Ultrasound in 3rd
trimester
Serial antenatal
ultrasound every
4-5 wk
Refer to
Specialised
Centre
Postnatal
Ultrasound at 3-7
days of life
Postnatal
Ultrasound
Sinha A, Bagga A, Krishna A, Bajpai M, Srinivas M, Uppal R, Agarwal I. Revised guidelines on management of antenatal hydronephrosis. Indian pediatrics. 2013 Feb 1;50(2):215-31.

Fetal Interventions
 Diagnostic and Thrapeutic interventions are recommended for fetuses with
suspected lower urinary tract obstruction and oligohydroamnios (following
1-1 counselling)
 No Recommendation for Pregnancy termination with isolated HN.
 Before therapeutic interventions, fetal vesicocentesis for estimation of urine
electrolytes, B2 microglobulins and osmolality is performed to predict renal
maturity and function.
 Fetuses likely to benefit from the therapeutic interventions are:
1. Decreasing levels of fetal urine sodium (<100mg/dl)
2. Decreasing levels of fetal urine calcium (<8mg/dl)
3. Decreasing levels of fetal urine Osmolality (<200mOsm/kg)
4. Decreasing levels of fetal urine B2 macroglobulin (<4mg/L)
5. Decreasing levels of fetal urine Protein (<20mg/dL)
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Spitzer A. The current approach to the assessment of fetal renal function: fact or fiction?. Pediatric Nephrology. 1996 Apr 1;10(2):230-5.

Fetal Interventions
 Diagnostic and Thrapeutic interventions are recommended for fetuses with
suspected lower urinary tract obstruction and oligohydroamnios (following
1-1 counselling)
 No Recommendation for Pregnancy termination with isolated HN.
 Before therapeutic interventions, fetal vesicocentesis for estimation of urine
electrolytes, B2 microglobulins and osmolality is performed to predict renal
maturity and function.
 Predominant cause for lower urinary tract obstruction is PUV in male fetuses
and can be offered vesicoamniotic shunting or in utero endoscopic ablation
of valves.
 Therapeutic interventions are performed in 2nd trimester preferably.
 Metaanalysis suggest that vesicoamniotic shunting improves perinatal
survival in fetuses with severe obstruction. But no evidence of improvement
in long term renal outcomes or reduced mortality in less severe diseases.
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1. Passerotti CC, Kalish LA, Chow J, Passerotti AM, Recabal P, Cendron M, Lee RS, Lopez AB, Retik AB, Nguyen HT. The predictive value of the first postnatal ultrasound in children with antenatal hydronephrosis. Journal of pediatric urology. 2011 Apr 1;7(2):128-36.
Postnatal Monitoring
 First postnatal ultrasound examination  within 1st week of life.
 Unilateral HN  within 3-7 days of life Or before hospital discharge.
 Severe Bilateral HN/ Suspected Posterior urethral valves  1st scan within
24-48hr.
 USG in first few days of life underestimates the degree of pelvic dilatation
due to dehydration and a relatively low urine output. So, delay beyond day 5
recommended usually.
 Evidence suggests that risk of postnatal pathology was 10.8% in infants with
normal postnatal ultrasound, as against 54.7% in those with persisting
hydronephrosis. (1)
 Negative predictive value of a normal postnatal USG for UTI was 98.9% (2)
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FIRST ULTRASOUND
2. Moorthy I, Joshi N, Cook JV, Warren M. Antenatal hydronephrosis: negative predictive value of normal postnatal ultrasound—a 5-year study. Clinical radiology. 2003 Dec 1;58(12):964-70.

 Severity of Postnatal hydronephrosis should be assessed as per classification
by Society For fetal Urology or AP Diameter of the renal pelvis.
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SEVERITY GRADING
1. Sidhu G, Beyene J, Rosenblum ND. Outcomeof isolated antenatal hydronephrosis: a systematic review and meta-analysis. Pediatric Nephrology. 2006 Feb 1;21(2):218-24.
2. Chertin B, Pollack A, Koulikov D, Rabinowitz R, Hain D, Hadas-Halpren I, Farkas A. Conservative treatmentof ureteropelvicjunction obstruction in children with antenatal diagnosis of hydronephrosis: lessons learned after 16 years of follow-up. European urology. 2006 Apr 1;49(4):734-9.

SEVERITY GRADING
SFU classification includes assessment of renal pelvic fullness, dilatation
of major and minor calyces and cortical thickness.

 Severity of Postnatal hydronephrosis should be assessed as per classification
by Society For fetal urology or AP Diameter of the renal pelvis.
 NEONATAL HYDRONEPHROSIS  defined as SFU grade ≥1 or Renal APD ≥
7mm.
 Metaanalysis suggests that isolated ANH was 5 times more likely to stabilize
if associated with SFU grade 1-2 or APD <12mm, than with SFU grade 3-4 or
APD >12mm. (1)
 SFU grade 3-4 was also found to be associated with high odds for surgery. (2)
 Postnatal ultrasound should also look for calyceal or ureteric dilatation,
cortical cyst and echogenicity, bladder wall abnormalities, ureterocele and
bladder emptying.
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SEVERITY GRADING
1. Sidhu G, Beyene J, Rosenblum ND. Outcomeof isolated antenatal hydronephrosis: a systematic review and meta-analysis. Pediatric Nephrology. 2006 Feb 1;21(2):218-24.
2. Chertin B, Pollack A, Koulikov D, Rabinowitz R, Hain D, Hadas-Halpren I, Farkas A. Conservative treatmentof ureteropelvicjunction obstruction in children with antenatal diagnosis of hydronephrosis: lessons learned after 16 years of follow-up. European urology. 2006 Apr 1;49(4):734-9.

 Neonates with antenatal hydronephrosis and a normal first week ultrasound
examination should have a repeat study at 4-6 weeks of life.
 Infants with isolated mild unilateral or bilateral HN (SFU GR1-2) should be
followed up by sequential USG to look for progression/ resolution.
 Follow up ultrasound studies are scheduled at 3 – 6 monthly interval till 2 yrs
of life and yearly thereafter till resolution. (Max till 5-6 yrs of life)
 Infants with SFU Gr 3-4 or APD >10mm at onset require closer follow up.
 USG at 4-6 weeks is more sensitive and specific for obstruction than 1st week
of life USG.
(due to low urine flow secondary to low GFR and dehydration)
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FOLLOWUP ULTRASOUND

Postnatal Evaluation Algorhithm
Postnatal Ultrasound
Initial Scan in 1st week ; Repeat scan at 4-6 weeks
No
Hydronephrosis
SFU grade 0, APD <7mm
1. Moderate/ Severe HN
SFU grade 3-4, APD>10mm
2. Mild HN with ureteric
dilatation
Mild Hydronephrosis
without ureteric
dilatation
SFU grade 1-2, APD 7-
10mm
No
Interventions
Sinha A, Bagga A,
Krishna A, Bajpai M,
Srinivas M, Uppal R,
Agarwal I. Revised
guidelines on
management of
antenatal
hydronephrosis. Indian
pediatrics. 2013 Feb
1;50(2):215-31.
Ultrasound q3-6
months till
resolution Vesicoureteric
Reflux
Antibiotic
Prophylaxis
Lower urinary
tract obstruction
Surgical
Intervention
No VUR
Micturating Cystourethrogram
Diuretic Renography
Not Obstructed Obstruction
Surgery, if the differential function low or further declines on followup.

 The Voiding Cystourethrogram is a dynamic test used to
demonstrates the lower urinary tract and helps to detect the
existence of any vesico-ureteral reflux, bladder pathology and
congenital or acquired anomalies of bladder outflow tract.
 It is performed by passing a catheter through the urethra into the
bladder, filling the bladder with contrast material and then taking
radiographs while the patient voids.
 Urograffin 60% used which is diluted with normal saline.
The estimated volume of contrast medium to be given during the
examination is determined mainly by the age of the child except
for children less than one year of age in whom it is determined by
weight.
 It includes radiographs in the following phases  Scout film, Filling
film, Voiding film, Post void film.
WHAT IS MCU/ Voiding cystourethrogram??

1. Unilateral or Bilateral Hydronephrosis with SFU
Grade 3-4 or APD >10mm or Ureteric dilatation.
2. Infants with mild grades of HN who show
progressive worsening hydronephrosis or
progressive thinning of parenchyma.
3. Infants with antenatally detected hydronephrosis
who develop Urinary tract infection.
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WHOM TO PERFORM ON???

1. Patients with ANH with suspected lower urinary tract
obstruction  24-72hrs of life.
2. All other (indicated) cases of ANH  4 – 6 weeks of life.
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WHEN TO PERFORM??

WHY TO PERFORM??
Patients with Lower urinary tract obstruction
Eg. Posterior urethral valves are at high risk for
progressive kidney disease and recurrent UTI, and
therefore early MCU indicated for prompt
interventions.
Vesicoureteric Reflux is noted in 8-38% population
with ANH as compared to <1% in general population.
Early diagnosis of Severe VUR help in early antibiotic
start and prevent recurrent UTI and its further
sequelae.

DIURETIC RENOGRAPHY
 Renography is the medical imaging of the kidney using
radionuclide material (such as Tc-99mMAG3), and viewed
with a Gamma camera.
 Also called Nuclear Renography or Radioisotope Renography
or Renal Scintigraphy.
 When Diuretics( IV Furosemide 1mg/kg) is used to facilitate
renal excretion  Diuretic renography.
 Radiopharmaceutical materials used are:
 Tc-99m-MAG3 (Mercapto Acetyl Tri Glycine)
 Tc-99m-DTPA (Diethylene Triamine Pent Acetate)
 EC (Ethyl Cysteine)
WHAT ARE RENOGRAPHY SCANS??

DIURETIC RENOGRAPHY
HOW IT WORKS??
Pre requisites: Ensure hydration. Oral hydration suffices.
Bladder catheterization not necessary (except in patient with suspected bladder
abnormality or post micturition films showing persistent contrast in bladder.)
Injection of radionuclide material (or radioactive
tracer/radiopharmaceutical) into the intravenous
system.
The compound is usually localized/excreted by a
specific organ (in this case, the kidneys)
Radionuclides contains radioactive atoms. When those
atoms decay, they emit gamma rays that are detected
by the gamma camera.

DIURETIC RENOGRAPHY
Three basic classes of radionuclide are employed in nuclear renography:
1.Filtered agents  DTPA and MAG3
They are filtered through the glomerulus. So, useful in measuring perfusion,
function (GFR), drainage (obstruction).
2.Excreted agents  MAG3, EC and Hipuran
These are excreted by the renal tubules. So, useful in evaluating tubular
function and in transplant cases.
3.Cortical imaging agents  DMSA and Glucoheptonate
These get accumulated in the cortex. So, useful in evaluating for renal scarring,
infarction, differential renal mass.
DIURETIC SCAN  About 15 minutes after injection of the radionuclide, IV
Furosemide (1mg/kg) is given.
If the obstruction is partial, it may be detected only with high urine flow. Lasix
helps to demonstrate partial obstruction by maximizing urine output.
WHICH RENOGRAPHY SCAN??
Nuclear renogram is always
checked in 3 panels:
1. Perfusion
2. Drainage/function
3. Curves/analysis

DIURETIC RENOGRAPHY
 Useful in evaluating the physiology/functioning of the kidney by monitoring flow of
radioisotope and how efficiently the kidneys absorb and pass it.
 Other modalities provide info mainly about anatomy of organs.
 Shows abnormalities in structure, size and shape of the kidneys.
 Differentiates between passive dilation and obstruction.
 Useful for Pre and Post renal transplant monitoring to check for the vascularity of the
kidney to be transplanted.
Advantages of Renography
Dis-advantages of Renography
 Radioactivity exposure.
 Cannot differentiate between cyst and tumors.
 It produces lower contrast images than KUB X-ray, CT and MRI.
 Time consuming. A typical scan takes 30 mins – 2 hours

DIURETIC RENOGRAPHY
1. Infants with moderate to severe unilateral or bilateral hydronephrosis
(SFU grade 3-4, APD >10mm), with ABSENT vesicoureteric reflux.
2. Infants with hydronephrosis and dilated ureters and ABSENT
vesicoureteric reflux.
3. Patients with vesicoureteric reflux with worsening hydronephrosis (to
look for coexisting PUJ obstruction) .
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WHOM TO PERFORM ON???

DIURETIC RENOGRAPHY
1. Preferably renography is performed at 6 – 8 wks of life.
(Since renal functional immaturity before that results in poor isotope uptake)
2. May be performed earlier in patients with severe
hydronephrosis and cortical thinning.
3. Repeat renography may be needed in some patients in few
patients with worsening of pelvicalyceal dilatation on USG.
(Timing not defined. Tracer used in first evaluation and timing of diuretic
administration should be similar in serial evaluations)
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WHEN TO PERFORM??
Diuresis renography in the evaluation and management of pediatric hydronephrosis: What have we learned? Bayne, C.E. et al.Journal of Pediatric Urology, Volume 15, Issue 2, 128 - 137
Sinha A, Bagga A, Krishna A, Bajpai M, Srinivas M, Uppal R, Agarwal I. Revised guidelines on management of antenatal hydronephrosis. Indian pediatrics. 2013 Feb 1;50(2):215-31.

DIURETIC RENOGRAPHY
 Normal renogram curve has an early peak (2-5min), rapidly descending
phase and almost complete renal emptying in 20 minutes.
 Satisfactory drainage spontaneously or post diuretic administration
rules out obstruction.
 Differential Renal function Estimation: Normal 45 – 55%.
Any value less than 40% is significant.
 Other parameters checked: Time for clearance of 50% of
radionucleotide (T1/2>20min)
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Clues to Interpretation

PROPHYLACTIC ANTIBIOTIC THERAPY
 Infants with ANH, including those in whom hydronephrosis has resolved postnatally have
an increased risk of UTI.
 Rates of UTI depend on severity, duration of HN and antibiotic use.
 Never evidence shows that most of the cases of isolated mild HN without prophylaxis,
have similar frequency of UTI in unilateral and bilateral cases.
 Coelho et al reported that infants with postnatal renal APD ≥10mm have significantly
increased risk of infections compared to the mild ones.
 A significant number of infections have been reported in the context of VUR, but also in
ureteric dilatation and obstructions.
 Dearth in literature about the exact role and long term benefit of prophylactic antibiotics
in all moderate to severe HN.
WHY TO START??

 Due to the increased risk of UTI in infants with HN, the 2009 American Urological Association
(AUA) update series on “Use of Antibiotics for Prevention and Treatment of Infections in
Pediatric Urology” recommended use of continuous antibiotic prophylaxis (CAP) in this
population for the first year of life. (1)
 More recent evidences suggested that not only may CAP not reduce the risk of UTI, but it may
contribute to the development of bacterial antibiotic resistance. (2)
 The 2009 Canadian Urological Association (CUA) guidelines on HN stated that the role of CAP is
controversial, providing Grade D recommendation. (3)
 A meta-analysis showed that there was no difference in UTI rates for patients with low-grade
(SFU I–II) HN receiving CAP compared to those receiving no treatment (2.2% vs. 2.8%; p=0.15).
However, in patients with high-grade (III–IV) HN, a significant decrease in UTI rates was
observed in those receiving CAP vs. those not receiving it (14.6% vs. 28.9%; p<0.01). (4)
WHERE DOES EVIDENCE STAND??
1. Easterbrook B, Capolicchio JP, Braga LH. Antibiotic prophylaxis for prevention of urinary tract infections in prenatal hydronephrosis: An updated systematic review. Canadian Urological Association Journal. 2017 Jan;11(1-
2Suppl1):S3.
2. Williams G, Craig JC. Long‐term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database of Systematic Reviews. 2019(4).
3. Psooy K, Pike J. Investigation and management of antenatally detected hydronephrosis. Canadian Urological Association Journal. 2009 Feb;3(1):69.
4. Braga LH, Mijovic H, Farrokhyar F, Pemberton J, DeMaria J, Lorenzo AJ. Antibiotic prophylaxis for urinary tract infections in antenatal hydronephrosis. Pediatrics. 2013 Jan 1;131(1):e251-61.

 Recent studies like RIVUR (Randomized Intervention for Children with Vesicoureteral Reflux) found
that ‘ Among children with VUR after UTI, antimicrobial prophylaxis was associated with a
substantially reduced risk of recurrence, but not of renal scarring.’(*)
 Evidence based disadvantages for long term prophylactic antibiotics:
i. High incidence of antibiotic resistance.
ii. Showed no evidence of it preventing renal scarring or long term sequaele.
iii. Most of the study designs were heterogenic
iv. Cumbersome daily dosing. (most of the positive result studies also looked at a non-compliance
rate >25%.)
 None of the studies justified giving long term antibiotic prophylaxis (as in the past) and managing
simple factors like constipation was far better in preventing UTI.
WHERE DOES EVIDENCE STAND??
* RIVUR Trial Investigators. Antimicrobialprophylaxis for childrenwith vesicoureteralreflux. New England Journal of Medicine. 2014 Jun 19;370(25):2367-76.

1. Infants with postnatally confirmed moderate to severe
hydronephrosis (SFU GR3-4, APD >10mm), while awaiting
evaluation.
2. Infants with postnatally confirmed hydronephrosis with ureteric
dilatation, while awaiting evaluation.
3. ????? Vesicoureteric Reflux *
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WHOM TO START??
Prophylactic antibiotics are not required in children with PUJ obstruction, PUV.
Can be offered for post surgical period or neurogenic bladder (on regular catheterization)

 No specific evidence based recommendations available.
 For our local Indian settings, prophylaxis can be offered to infants with VUR
as the risk of UTI is higher in that age group and investigations are not yet
complete.
 However, even in this setting, beyond 1 year of age, prophylaxis should not
continue for more than 6 months after the last UTI.
 Also, as the child gets older, diagnosing UTI is easier and hence prophylaxis
may not be needed.
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CAP for VUR ????
Singhal T, Shah N. (2019) IAP speciality series on: Rational antimicrobial practices in pediatrics.New Delhi, India. Jaypee brothers medical publishers.

1. Oral Cephalexin (15mg/kg/day) daily in first 3
months of life.
Amoxycillin is also being used in few cases.
1. Post 3 months:
 Oral Cotrimoxazole (1 - 2mg/kg/day) daily
 Oral Nitrofurantoin (1 – 2 mg/kg/day) daily
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WHAT TO START??

SURGICAL MANAGEMENT
1. Infants with lower urinary tract obstruction.
2. Infants with obstructed hydronephrosis with reduced differential renal
function and/or worsening functions on repeat evaluations.
3. Patients with bilateral hydronephrosis or Hydronephrosis in solitary kidney
showing worsening of dilatation and functional deterioration(reduction in
differential function by 5 – 10% on renography).
4. Large hydronephrosis with Pain, discomfort, palpable renal lump or recurrent
UTI
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WHOM TO OPERATE??

SURGICAL MANAGEMENT
1. Prevent loss of renal function
2. Reduce the degree of hydronephrosis and
associated symptoms.
3. Improve the renal pelvis evacuation
R
E
C
O
M
M
E
N
D
A
T
I
O
N
S
WHY TO OPERATE??

SURGICAL MANAGEMENT
WHICH SURGERY INTERVENTIONS??
Posterior Urethral Valves 
Early urethral catheterization,
Dyselectrolytemia correction &
CYSTOSCOPIC ABLATION OF VALVES.
Pelviureteric junction obstruction with
differential function <40%  Pyeloplasty
(Laproscopic or retroperitoneoscopic)

SURGICAL MANAGEMENT
Infants with differential renal function >40% can be managed
conservatively.
(with close followup and serial USG monitoring)
R
E
C
O
M
M
E
N
D
A
T
I
O
N
S
WHOM NOT TO OPERATE??

ALGORITHM
FOR MANAGEMENT OF
ANTENATAL HYDRONEPHROSIS

Antenatal Hydronephrosis

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Antenatal Hydronephrosis